spine fellowship - open position

[axm397]

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There is a PM&R PASSOR spine fellowship position available in California. The fellow will spend time doing EMGs and spinal procedures. please pm me if interested

 

[axm397]

TITLE
The LA Spine Institute Fellowship Program

DESCRIPTION
The The LA Spine Institute Fellowship Program is designed to train a prospective fellow in multidisciplinary approaches to the management of non-operative spine diseases. This is a non-ACGME program, which will begin its inaugural class starting July 7, 2008.

The spine fellow will work with physiatrists, anesthesiologists, neurologists, Orthopaedic surgeons, Neurosurgeons, psychiatrists and psychologists in obtaining expertise in multidisciplinary spine management. The non-operative program training will include the prescription of physical therapy/modalities as well as obtain exposure to the use of narcotics and adjuvant medications when addressing patients with spine issues. Training in interventional spine procedures (epidurals, etc&#8230😉, Electrodiagnostic Medicine and surgical procedures (Dorsal Column Stimulators) will also be emphasized.

A large focus will also be dedicated to the learning of Electrodiagnostic Studies and the how to work up a patient with spine pain to include differential diagnosis for musculoskeletal disease entities that mimic symptoms of spinal radiculopathy (carpal tunnel syndrome, shoulder impingement, and hip pain, etc&#8230😉. Furthermore, in addition to general musculoskeletal disorders, there will be some exposure to spinal source headaches and palliative and cancer spine pain. The Spine fellow will also be responsible for the coordination of patient care between various services and assist in the education of PM&R residents as well as medical students.

TRAINING CENTERS:
1. Santa Monica UCLA Medical Center and Orthopaedic Hospital
2. Los Angeles Spine Institute
3. Beverly Hills Orthopaedic Group

GOALS:
The goals and objectives for the Spine Medicine Fellow are:
To gain the fundamental knowledge base required for the practice of comprehensive spine pain medicine.
To acquire the skills of patient assessment necessary for the provision of optimal treatment plans in spine pain patients.
To gain sufficient skill and judgment to ensure the appropriate use and application of the various spine pain management interventions and procedures that are considered a standard-of-care.
To gain an understanding of the multidisciplinary nature of spinal pain management, and to be able to coordinate and function in a collaborative fashion with other healthcare professionals.
To be gain competency in the prescription of medications, modalities, therapies, relating to spinal pain management.
To gain competency is basic electrodiagnostic skills for use with spinal disorder work up.
All interested applicants should send or fax the following information:

1. Cover Letter and Statement of Purpose
2. Curriculum Vitae (Please include all contact numbers and e-mail)
3. 3 letters of recommendation
4. Relevant information such as Board Scores, Honor Certificates, and
Diplomas
5. USMLE 3 parts and SAE scores
6. Dean's Letter from Medical School
7. Medical School Transcript



For all general program inquiries please contact Dr. Davis:

To APPLY FOR THE LA SPINE INSTITUTE POSITION, please send all information to:
The Spine Institute PM&R Fellowship
Timothy T. Davis, MD
1301 20th St Ste 400
Santa Monica CA 90404
Phone: (310) 828-7757

email all CV and personal statements to: [email protected]

 

[Disciple]

Axm,

off track a little bit, but I was just wondering what the rational behind the new fellowship was.

I thought Dr. Fish was an adovcate of comprehensive PM&R "pain" training.

Has there been a change of heart?

 

[ampaphb]

TITLE
The UCLA PMR Spine Medicine Fellowship Program

DESCRIPTION
The UCLA PMR Spine Medicine Fellowship Program is designed to train a prospective fellow in multidisciplinary approaches to the management of non-operative spine diseases. This is a non-ACGME program, which will begin its inaugural class starting July 7, 2008.

The spine fellow will work with physiatrists, anesthesiologists, neurologists, Orthopaedic surgeons, Neurosurgeons, psychiatrists and psychologists in obtaining expertise in multidisciplinary spine management. The non-operative program training will include the prescription of physical therapy/modalities as well as obtain exposure to the use of narcotics and adjuvant medications when addressing patients with spine issues. Training in interventional spine procedures (epidurals, etc…), Electrodiagnostic Medicine and surgical procedures (Dorsal Column Stimulators) will also be emphasized.

A large focus will also be dedicated to the learning of Electrodiagnostic Studies and the how to work up a patient with spine pain to include differential diagnosis for musculoskeletal disease entities that mimic symptoms of spinal radiculopathy (carpal tunnel syndrome, shoulder impingement, and hip pain, etc…). Furthermore, in addition to general musculoskeletal disorders, there will be some exposure to spinal source headaches and palliative and cancer spine pain. The Spine fellow will also be responsible for the coordination of patient care between various services and assist in the education of PM&R residents as well as medical students.

TRAINING CENTERS:
1. Santa Monica UCLA Medical Center and Orthopaedic Hospital
2. Los Angeles Spine Institute
3. Beverly Hills Orthopaedic Group

GOALS:
The goals and objectives for the Spine Medicine Fellow are:
To gain the fundamental knowledge base required for the practice of comprehensive spine pain medicine.
To acquire the skills of patient assessment necessary for the provision of optimal treatment plans in spine pain patients.
To gain sufficient skill and judgment to ensure the appropriate use and application of the various spine pain management interventions and procedures that are considered a standard-of-care.
To gain an understanding of the multidisciplinary nature of spinal pain management, and to be able to coordinate and function in a collaborative fashion with other healthcare professionals.
To be gain competency in the prescription of medications, modalities, therapies, relating to spinal pain management.
To gain competency is basic electrodiagnostic skills for use with spinal disorder work up.
All interested applicants should send or fax the following information:

1. Cover Letter and Statement of Purpose
2. Curriculum Vitae (Please include all contact numbers and e-mail)
3. 3 letters of recommendation
4. Relevant information such as Board Scores, Honor Certificates, and
Diplomas
5. USMLE 3 parts and SAE scores
6. Dean’s Letter from Medical School
7. Medical School Transcript



For all general program inquiries please contact:

Dr. David Fish, Program Director: [email protected]

Interesting - why did you and Chris opt for the ACGME accredited spots, as opposed to this one? Other than locations, how will this be different from the training you anticipate receiving there?

 

[axm397]

disciple - there is no change of heart. The ACGME accredited pain fellowship is not affected by this new spine fellowship. The timing was right and opportunities for even more spinal procedures than what the pain fellows can take advantage of existed so Dr. Fish just put the scattered opportunities together to form this spine fellowship. Although there are similarities and overlap between the two fellowships, the focus and objectives are different.

ampaphb - I can't speak for chris but I wanted to pursue a career in academic pain and perhaps work for an accredited fellowship - so I wanted the ACGME accreditation. I also am more interested in pain overall - not just spine pain. I wanted a program with exposure to all types of pain including CRPS, cancer pain, headache, etc. I am involved in research studies about CRPS and knee OA right now - and was involved with a treatment outcomes of pain study in med school so you can see how my interests do not quite mesh with the learning objectives of this fellowship. I also wanted the opportunity to teach med students and residents and work closely with the UCLA PM&R faculty members. This position is more of a "spine" fellowship - i.e. concentrating on spinal diagnoses and procedures. The faculty members are more spine oriented and this fellow looks like will spend less time with residents/med students than the pain fellows.

That all being said, I think this is an excellent opportunity for those interested in learning spine procedures and becoming fellowship trained. Dr. Fish is an energetic teacher with a lot to offer.

 

[Disciple]

Sounds similar to a previous thread about the Cleveland Clinc and their new "spine" fellowship.

I'm sure the UCLA spine fellowship will provide great training.


It just begs the question:

Is there an existing body of knowledge of sufficient depth to create non-operative spine specialists separate from Pain Medicine Specialists?


Some would say yes.

 

[Louisville04]

Are ACGME accredited fellowships (usually anesthesia pain fellowships) funded by the government while not accredited fellowships (usually spine fellowships) funded by the doctor/group sponsoring it?

 

[ampaphb]

Sounds similar to a previous thread about the Cleveland Clinc and their new "spine" fellowship.

I'm sure the UCLA spine fellowship will provide great training.


It just begs the question:

Is there an existing body of knowledge of sufficient depth to create non-operative spine specialists separate from Pain Medicine Specialists?


Some would say yes.

I personally believe this is an artificial distinction. For instance, CRPS, while presenting peripherally, generally is addressed centrally. Likewise the vast majority of interventions done for headaches address the cervicogenic variety (a subset the average neurologist has very little experience with).

Admittedly, cancer and peds are different, and those may well be where an ACGME Pain fellowships excel, but for the vast majority of pain practitioners , those subjects do not amount to more than 1-2% of their practice, and so, I would contend, ought not to dictate the type of training one seeks out.

BTW, there is nothing NEW about the Cleveland Clinic's spine fellowship (if you look, you will see it listed on the Pain Rounds Interventional Physiatry Fellowship directory (http://painrounds.com/index.php?option=com_content&task=view&id=22&Itemid=28), and that has not been updated in SEVERAL years)

Baylor, MCV, and now UCLA are new within the past year, but I believe the Cleveland Clinic fellowship has existed for quite some time

 

[paindefender]

Our hospital requires ABMS pain certification in order to perform neuroaxial procedures. I see more hospitals following this trend in the future. For those who want to perform interventional pain procedures, I suggest to stay away from non accredited "fellowships".

 

[SSdoc33]

For those who want to perform interventional pain procedures, I suggest to stay away from non accredited "fellowships".

wrong.

this topic has been covered ad nauseum, but to state the above is irresponsible.

 

[ampaphb]

Our hospital requires ABMS pain certification in order to perform neuroaxial procedures. I see more hospitals following this trend in the future. For those who want to perform interventional pain procedures, I suggest to stay away from non accredited "fellowships".

Sounds like an excellent reason to do your procedures in the local ASC, but not a terribly good rationale for obtaining less than optimal training.

Given that only a few PM&R-based ACGME-accredited fellowships remain, it strikes me that a lawsuit is inevitable, should a medical staff actually try and refuse a felowship-trained interventionist privileges. I such a suit were to allege restraint of trade and violations of antitrust law, it might well be successful.

 

[Disciple]

I personally believe this is an artificial distinction. For instance, CRPS, while presenting peripherally, generally is addressed centrally. Likewise the vast majority of interventions done for headaches address the cervicogenic variety (a subset the average neurologist has very little experience with).

Admittedly, cancer and peds are different, and those may well be where an ACGME Pain fellowships excel, but for the vast majority of pain practitioners , those subjects do not amount to more than 1-2% of their practice, and so, I would contend, ought not to dictate the type of training one seeks out.

BTW, there is nothing NEW about the Cleveland Clinic's spine fellowship (if you look, you will see it listed on the Pain Rounds Interventional Physiatry Fellowship directory (http://painrounds.com/index.php?option=com_content&task=view&id=22&Itemid=28), and that has not been updated in SEVERAL years)

Baylor, MCV, and now UCLA are new within the past year, but I believe the Cleveland Clinic fellowship has existed for quite some time

In your opinion, then, should spine fellowships exist?

With limited healthcare resources, are they redundant, a duplication of efforts?

By the reasoning you've presented above, primary care sports med could be classified under "Pain Medicine" as well, e.g.

-Athlete gets injured
-injury causes "pain"
-athlete is unable to perform due to "pain"

What about Occ Med?

I guess the question I'm asking is: Is non-operative spine care complex enough a subject matter to stand alone, as a medical specialty, or is it really Pain Medicine lite. If we say yes, then spine fellowships should exist. If we say no, then they should not.

Regarding the Cleveland Clinic spine fellowship, I could be wrong, but it doesn't sound like the fellowship described here

http://forums.studentdoctor.net/showthread.php?t=398012&highlight=nagy

is the same fellowship that has been listed in the PASSOR guide for the past several years.

 

[ampaphb]

I am struck that the only difference between pain fellowships and spine fellowships is that one is eligible for ACGME accreditation, and one is not.

Practices distinguish themselves as "spine" if they do not want to focus their efforts on opioid renewals. I don't think that makes them "lite" or any less sophisticated than their pain colleagues.

In my community, patients are sent to the spinal interventionist for diagnostic and therapeutic injections. If they work, great. If they don't they are then sent back to the spine surgeon, who either operates, or sends them on to the pain doc, who usually employs medication management as his primary therapeutic modality.

Given the surgical nature of pumps and stims, as well as the arthroscopic procedures folks like Algos perform, I have never thought "Non-Operative spine" was a reasonable descriptor of what we do. It has the same ring to it as "Orthopaedic Medicine", a term physiatrists and chiropractors have both used to try and poach patients from the orthopods

 

[paindefender]

Sounds like an excellent reason to do your procedures in the local ASC, but not a terribly good rationale for obtaining less than optimal training.

Given that only a few PM&R-based ACGME-accredited fellowships remain, it strikes me that a lawsuit is inevitable, should a medical staff actually try and refuse a felowship-trained interventionist privileges. I such a suit were to allege restraint of trade and violations of antitrust law, it might well be successful.

Lawsuits are costly and lengthy. I would rather spend my time, money and energy in finding an accredited fellowship.

 

[paindefender]

wrong.

this topic has been covered ad nauseum, but to state the above is irresponsible.

I don't think that suggesting training with established standards and guidelines is irresponsible.

 

[Disciple]

I am struck that the only difference between pain fellowships and spine fellowships is that one is eligible for ACGME accreditation, and one is not.

Practices distinguish themselves as "spine" if they do not want to focus their efforts on opioid renewals. I don't think that makes them "lite" or any less sophisticated than their pain colleagues.

In my community, patients are sent to the spinal interventionist for diagnostic and therapeutic injections. If they work, great. If they don't they are then sent back to the spine surgeon, who either operates, or sends them on to the pain doc, who usually employs medication management as his primary therapeutic modality.

Given the surgical nature of pumps and stims, as well as the arthroscopic procedures folks like Algos perform, I have never thought "Non-Operative spine" was a reasonable descriptor of what we do. It has the same ring to it as "Orthopaedic Medicine", a term physiatrists and chiropractors have both used to try and poach patients from the orthopods

I didn't mean to imply "less sophisticated", but to present both sides of the argument, a pain physician may say

"I am the equivalent of the spinal interventionist, plus, the knowledge and skills to manage every other form of pain not related to orthopaedic or degenerative spinal disorders"

whereas the interventional spine guy may say

"I have limited skills in the broad management of "pain" ,but, I have a deeper knowledge of the bio/kinematics/functional anatomy of the spine in addition to the pathophys, evaluation and management of simple to the most complex of spinal disorders.

They can't both be right.

 

[paindefender]

The advantages of a spine interventionist is that after he/she has performed all possible procedures, he/she can refer the patient to a pain doc for pain control.

 

[drusso]

Oh good, since we've all decided to dig up the horse and drag him out into the pasture, I can't wait to take a smack at it!



Disciple asks the right question:

Is there an existing body of knowledge of sufficient depth to create non-operative spine specialists separate from Pain Medicine Specialists?

My answer is "No." The real problem is the primary certification in PM&R does not live up to its promise of making everyone who becomes certified a non-operative MSK (MSK system includes the Spine) expert. Which is a shame, because it should. It is the equivalent of completing an internal medicine residency and never really "getting around" around to the kidney. Or completing an anesthesia residency and not "getting around" to learning how to manage a vent.

Some physiatrists get OUTSTANDING Spine and MSK Medicine experience in their training programs, most get mediocre experience, and some still, despite 20 years of hard work by PASSOR whose vision explicitly states, "Physiatrists are recognized as the experts in functional musculoskeletal rehabilitation," get almost no meaninful training in MSK Medicine at a level consistent with the depth and breadth expected in a SPECIALIST training program.

If physiatrists are to be "recognized as the experts in functional musculoskeletal rehabilitation," then they must be equipped with the tools to diagnose and treat MSK conditions at the level of a specialist. It is the job of PM&R residency programs to do this. Diagnostic neuraxial procedures are important tools to diagnose spinal conditions? Why don't *ALL* PM&R residents do 200 image-guided lumbar spine interventions as a required part of their training?

Such training would be OUTSTANDING preparation for a subsequent interventional pain fellowship that would teach neuraxial procedures at all levels, sympathetic blocks, intrathecal therapy and neuromodulation for those who were interested in these advanced procedures. Of course, it might mean taking more time away from hospital consults and running inpatient units which seems to be the proverbial Mother's Milk for most academic physiatry departments...

Thus, the dirty secret is that while there are some excellent PM&R training programs, the field as a whole, depends upon post-residency quasi-preceptorship-fellowship arrangements for remedial education. Whatever your PM&R program was lacking, you can make-up for by doing a "fellowship." There would be no need for "Interventional Spine" fellowships if basic interventional spine procedures were part and parcel of primary certification in PM&R.

 

[paindefender]

My answer is "No." The real problem is the primary certification in PM&R does not live up to its promise of making everyone who becomes certified a non-operative MSK (MSK system includes the Spine) expert. Which is a shame, because it should. It is the equivalent of completing an internal medicine residency and never really "getting around" around to the kidney. Or completing an anesthesia residency and not "getting around" to learning how to manage a vent.

Some physiatrists get OUTSTANDING Spine and MSK Medicine experience in their training programs, most get mediocre experience, and some still, despite 20 years of hard work by PASSOR whose vision explicitly states, "Physiatrists are recognized as the experts in functional musculoskeletal rehabilitation," get almost no meaninful training in MSK Medicine at a level consistent with the depth and breadth expected in a SPECIALIST training program.

If physiatrists are to be "recognized as the experts in functional musculoskeletal rehabilitation," then they must be equipped with the tools to diagnose and treat MSK conditions at the level of a specialist. It is the job of PM&R residency programs to do this. Diagnostic neuraxial procedures are important tools to diagnose spinal conditions? Why don't *ALL* PM&R residents do 200 image-guided lumbar spine interventions as a required part of their training?

Such training would be OUTSTANDING preparation for a subsequent interventional pain fellowship that would teach neuraxial procedures at all levels, sympathetic blocks, intrathecal therapy and neuromodulation for those who were interested in these advanced procedures. Of course, it might mean taking more time away from hospital consults and running inpatient units which seems to be the proverbial Mother's Milk for most academic physiatry departments...

Thus, the dirty secret is that while there are some excellent PM&R training programs, the field as a whole, depends upon post-residency quasi-preceptorship-fellowship arrangements for remedial education. Whatever your PM&R program was lacking, you can make-up for by doing a "fellowship." There would be no need for "Interventional Spine" fellowships if basic interventional spine procedures were part and parcel of primary certification in PM&R.[/QUOTE]



I agree

 

[SSdoc33]

i think that everyone would agree that there are SOME interventional spine fellowships that provide better training for spine disorders than SOME acgme accredited pain programs. higher volume, more emphasis on physical exam, broader exposure to procedures, etc. the interventional spine fellow could therefore learn more in-depth spine care and sacrifice expertise in opioid management, cancer pain, facial pain, etc.

just because you complete an ACGME accredited pain fellowship does not mean that you are necessarily better or more qualified to perform these neuraxial procedures. a hospital-based, anesthesia run, pain department at a large academic center may think so. fine. no problem with that. ill do my procedures in the office or ASC and get the lion's share of the reimbursement.

paindefender needs to get off of his high - "I AM THE ANESTHESIA PAIN GOD AND ALL LOWLY PHYSIATRISTS MUST KNEEL BEFORE ME!!!!" - horse.

 

[Ligament]

i think that everyone would agree that there are SOME interventional spine fellowships that provide better training for spine disorders than SOME acgme accredited pain programs. higher volume, more emphasis on physical exam, broader exposure to procedures, etc. the interventional spine fellow could therefore learn more in-depth spine care and sacrifice expertise in opioid management, cancer pain, facial pain, etc.

just because you complete an ACGME accredited pain fellowship does not mean that you are necessarily better or more qualified to perform these neuraxial procedures. a hospital-based, anesthesia run, pain department at a large academic center may think so. fine. no problem with that. ill do my procedures in the office or ASC and get the lion's share of the reimbursement.

paindefender needs to get off of his high - "I AM THE ANESTHESIA PAIN GOD AND ALL LOWLY PHYSIATRISTS MUST KNEEL BEFORE ME!!!!" - horse.

SSdoc33, you need to be informed that paindefender is 100% troll. He/she/it consistently trolls on this forum. paindefender is almost as inflammatory as paz and almost as inflamed as gorback...😛😛😛

 

[drusso]

i think that everyone would agree that there are SOME interventional spine fellowships that provide better training for spine disorders than SOME acgme accredited pain programs. higher volume, more emphasis on physical exam, broader exposure to procedures, etc. the interventional spine fellow could therefore learn more in-depth spine care and sacrifice expertise in opioid management, cancer pain, facial pain, etc.

No doubt, but what is best for the LONG-TERM?? Does the health care system really NEED this? Are patients better served by having Pain Specialists and Interventional Spine Specialists? Should IS fellowships become ACGME-accredited? Why or why not?

My proposed solution is to roll what gets covered in an interventional spine fellowship back into the core PM&R training as the overwhelming majority of interventional spine fellowships are run by physiatrists or physiatry groups. If that means taking away from traditional neurorehab, then those residents who feel like their neurorehab training was insufficient to prepare them for practice can do a fellowship...

Neither neurology nor anesthesia academic programs sponsor interventional spine fellowships--only physiatry does. Yet, all three specialties sponsor pain fellowships...

Why does physiatry feel the need to create "something out of nothing?" Does the field *REALLY* need another sub-specialty? 🙄

 

[paindefender]

SSdoc33, you need to be informed that paindefender is 100% troll. He/she/it consistently trolls on this forum. paindefender is almost as inflammatory as paz and almost as inflamed as gorback...😛😛😛

I don't see the troll. Some readers find the truth hard to handle. Calling it a troll is an easy way out.

 

[Disciple]

paindefender needs to get off of his high - "I AM THE ANESTHESIA PAIN GOD AND ALL LOWLY PHYSIATRISTS MUST KNEEL BEFORE ME!!!!" - horse.

I think paindefender is a Physiatrist.

One that's angry about having had to train on the East Coast or something.

 

[paindefender]

I think paindefender is a Physiatrist.

One that's angry about having had to train on the East Coast or something.

Last time you asked me if I was a Physiatrist, I answered you truthfully.

 

[Disciple]

I don't remember you answering.

 

[Disciple]

No doubt, but what is best for the LONG-TERM?? Does the health care system really NEED this? Are patients better served by having Pain Specialists and Interventional Spine Specialists? Should IS fellowships become ACGME-accredited? Why or why not?

My proposed solution is to roll what gets covered in an interventional spine fellowship back into the core PM&R training as the overwhelming majority of interventional spine fellowships are run by physiatrists or physiatry groups. If that means taking away from traditional neurorehab, then those residents who feel like their neurorehab training was insufficient to prepare them for practice can do a fellowship...

That's the ideal solution, but, I think we need to be reallistic about what we would like to happen and what will probably happen. I don't think you could ever get 100 or near 100% compliance from PM&R residencies. The best we could hope for would be a hybrid model, ala plastics fellowships/intergrated plastics residencies?

Neither neurology nor anesthesia academic programs sponsor interventional spine fellowships--only physiatry does. Yet, all three specialties sponsor pain fellowships...

Why does physiatry feel the need to create "something out of nothing?" Does the field *REALLY* need another sub-specialty? 🙄

I think it's just the way things developed chronologically. Pain management filled a void with meds and palliative procedures when there was no such thing as musculoskeletal Physiatry and it was thought that meds, injections and psyche were pretty much it for chronic back pain/orthopaedic pain. Who knows what we would have today if Physiatry didn't take the inpt turn way back when, after starting out based mainly on Physical Medicine.

Though I have no doubt that the UCLA spine fellowship would put out a good Interventional Physiatrist, the thing that strikes me as kind of odd is that there would be a PMR "spine" fellowship and a PMR "pain" fellowship at the same institution.

Now, either, you believe that spine fellowships are legitimate or they aren't. With what's described above (new UCLA fellowship), it sounds like the spine fellow would be doing basic leftover procedures from the pain fellowship and that the spine fellow would be doing the same spine rotation as the pain fellows except for 12 months instead of 3. Alot of the argument on "spine" vs "pain" is based on perception as variety/depth of skills and knowledge are highly variable, and what's described above makes it sound like the fellowship is geared more toward what some may see as Pain Medicine lite.

My point is, that if you want to make the argument that "spine" fellowships are justified, i.e. provide a more in depth knowledge of spinal disorders and spine related pain, then the training needs to reflect that (across the board-preferrably). Maybe 2-3 months learning from good PTs or at a fellowship like Mike Geraci's or RIC, maybe weekly chapter review that covers the entirety of Slipman's book over the course of a year, maybe clinic days and scrubbing with the spine surgeons, who knows?

 

[ampaphb]

Look to the upper left of this web page - Click on My Account, then scroll down to Control Panel > Miscellaneous > Buddy / Ignore Lists - under Ignore List, enter the name of your favorite troll, and Voilà! 🙂 no more Paindefender

 

[SSdoc33]

No doubt, but what is best for the LONG-TERM?? Does the health care system really NEED this? Are patients better served by having Pain Specialists and Interventional Spine Specialists? Should IS fellowships become ACGME-accredited? Why or why not?

My proposed solution is to roll what gets covered in an interventional spine fellowship back into the core PM&R training as the overwhelming majority of interventional spine fellowships are run by physiatrists or physiatry groups. If that means taking away from traditional neurorehab, then those residents who feel like their neurorehab training was insufficient to prepare them for practice can do a fellowship...

Neither neurology nor anesthesia academic programs sponsor interventional spine fellowships--only physiatry does. Yet, all three specialties sponsor pain fellowships...

Why does physiatry feel the need to create "something out of nothing?" Does the field *REALLY* need another sub-specialty? 🙄

"if man is to fly one day, he must first learn to stand and walk. one cannot fly into flying" (nietzsche via "coming to america")


i do agree that the best solution is to enforce residency programs to get off their butts and have structured requisites, like with EMGs. do you honestly see that happening anytime soon? the problem is that the field is so fractured that it has no identity. reading through braddom or delisa literally makes me say "WTF is all this $#$@?". why do i need to read 50 pages on burn rehab when i may never come across that patient in my entire career? do i really need to know all 8 types of HSMN? peds? 1 hour ASIA exams.... really? the problem is that the field is WAY too broad to master any one aspect of it in residency. i agree that should change, but that change will happen at a snails pace.

is there a need for separate "interventional spine" and "pain" subspecialties. i do think that there are enough patients with back and neck pain to support the 2 different tracts. but ideally, no, there should be one subspecialty that deals with it all. that means that anesthesiologists (take it easy everyone) might have to learn a better physical exam. that means that physiatrists may need better knowledge of pain pathophysiology and medications and needle skills, etc. that means neurologists might have to learn to treat, rather than solely diagnose. there is certainly significant overlap between the two tracts, but there are differences which appear to be irreconcileable. the way that each field practices will not easily be incorporated into each other. the recent move towards a multidisciplinary ACGME pain program model is a good step, but that step was towards anesthesia and "pain" more than physiatry and "spine".

what is better for the health care system? cutting down the number of unnecessary spine surgeries would be the first step. a great way to do that would be to have provide exemplary multidisciplinary spine care that the insurance companies will recognize.

 

[ampaphb]

Are you a Physiatrist, Paindefender?

I would rather work in Mcdonald's

Res ipsa loquitur

 

[Disciple]

Reading other posts, I didn't believe it.

 

[paindefender]

Res ipsa loquitur

Didn't you use the ignore function for paindefender?

 

[axm397]

With what's described above (new UCLA fellowship), it sounds like the spine fellow would be doing basic leftover procedures from the pain fellowship and that the spine fellow would be doing the same spine rotation as the pain fellows except for 12 months instead of 3. Alot of the argument on "spine" vs "pain" is based on perception as variety/depth of skills and knowledge are highly variable, and what's described above makes it sound like the fellowship is geared more toward what some may see as Pain Medicine lite.

The spine fellow rotations and the pain fellow rotations really don't have much overlap. The pain fellows don't rotate at 2 of the 3 sites and the 1 overlap site - the spine fellow will primarily perform EMGs. So it's really not a matter of the spine fellow getting "leftover" procedures. The faculty is different - with a few overlaps - and the curriculum is different.

 

[Disciple]

The reason I had asked if there was a change of heart is because it just seems that creation of a new "spine" fellowship is not congruent with posts Dr. Fish had made previously.

I agree with the AAPMR/PASSOR focus away from pain and more to the spine/MSK, but have felt that this is short sighted.

 

[defphiche]

Well, I appreciate everyone's input. I guess I can only summarize my Spine Fellowship as an opportunity. I had the opportunity to give someone an great experience and could not find an ACGME label for it. While this fellowship in spine has new attending staff that the current pain fellows are only marginally exposed to, I was unable to make this ACGME for many political reasons. The bottom line is that the person who takes this spot needs to know that they can't sit for the pain boards. I was approached by two fantastic private practice attendings (PMR and Ortho Spine), both on UCLA clinical staff. I could not pass this up due to the funding that came with the spot. I am always pushing for ACGME, but giving this opportunity for an excellent candidate was not right since so many applied to pain.

 

[Ligament]

Well, I appreciate everyone's input. I guess I can only summarize my Spine Fellowship as an opportunity. I had the opportunity to give someone an great experience and could not find an ACGME label for it. While this fellowship in spine has new attending staff that the current pain fellows are only marginally exposed to, I was unable to make this ACGME for many political reasons. The bottom line is that the person who takes this spot needs to know that they can't sit for the pain boards. I was approached by two fantastic private practice attendings (PMR and Ortho Spine), both on UCLA clinical staff. I could not pass this up due to the funding that came with the spot. I am always pushing for ACGME, but giving this opportunity for an excellent candidate was not right since so many applied to pain.

How did defphiche become a pain medicine forum moderator? He has 14 posts since 2005?!? I'm always VERY happy to see fellowship directors on this forum but one would think PARTICIPATION in the forum is required to become a moderator!

 

[lobelsteve]

How did defphiche become a pain medicine forum moderator? He has 14 posts since 2005?!? I'm always VERY happy to see fellowship directors on this forum but one would think PARTICIPATION in the forum is required to become a moderator!

The odometer rolled over. It's 1,000,014

 

[defphiche]

Ligament,

I fully agree with you on this. I was asked to be a moderator and said that I didn't have the time. I have no problem stepping down from the moderator position, but am unsure how to do this. Please forgive my lack of participation, I have other commitments that are taking up my time.

 

[ampaphb]

Ligament,

I fully agree with you on this. I was asked to be a moderator and said that I didn't have the time. I have no problem stepping down from the moderator position, but am unsure how to do this. Please forgive my lack of participation, I have other commitments that are taking up my time.

Dr. Fish:

Whether in the position of moderator or not, I for one appreciate the fact that you share your insights with the members of Pain Rounds.

It is people like you, Dr. Shah of Texas Tech, and Dr. Lobel, formerly of Emory, who bring credibility to this board.

Why does anyone care if Dr. Fish is a moderator or not - so long as, when the need arises, he is available to clarify what is going on at UCLA, or fellowships as a whole, I say thanks for stopping by whenever time permits.

 

[Ligament]

Ligament,

I fully agree with you on this. I was asked to be a moderator and said that I didn't have the time. I have no problem stepping down from the moderator position, but am unsure how to do this. Please forgive my lack of participation, I have other commitments that are taking up my time.

Dr. Fish, there are no need for apologies. Again, I am very pleased to have fellowship directors on this board. VERY pleased. Everybody here welcomes you, regardless of the frequency you can participate.

My point is simply that we have other physicians on this forum, that post very regularly, that are qualified to be a moderator, yet they go unrecognized.

 

[Ligament]

Dr. Fish:

Whether in the position of moderator or not, I for one appreciate the fact that you share your insights with the members of Pain Rounds.

It is people like you, Dr. Shah of Texa Tech, and Dr. Lobel, formerly of Emory, who bring credibility to this board.

Why does anyone care if Dr. Fish is a moderator or not - so long as, when the need arises, he is available to clarify what is going on at UCLA, or fellowships as a whole, I say thanks for stopping by whenever time permits.

ampaphb, I can't argue with your sentiments. This is really not a huge deal to me, I was just surprised to see Dr. Fish listed as a moderator, when other well known attendings on this board that participate very frequently are not recognized as such.

I am very happy to see Dr. Fish on SDN and welcome him whenever he can find time to drop by.

I'm happy to drop this issue and hope there were no hurt feelings; none intended!

 

[defphiche]

Well, the backlash from this fellowship turned out to be more political than i thought. I will step down from this fellowship director position for the NON-ACGME spine fellowship and hand the directorship over to the major funding source for the position, Dr. Tim Davis.

Dr Davis is the PMR attending at the LA Spine Institute in Santa Monica at Saint Johns and he will now be the acting program director for the spine fellowship.

I will be involved as one of the staff attendings but the bulk of the training as per our schedule originally, will be at the LA Spine Institute.

I will have to agree that the NON-ACGME spine program compromised my ACGME position at WLA VA/UCLA pain program.

The opportunity position will still be available, but will not be called UCLA at this time.

Sorry for the confusion and thank you for the comments.

To APPLY FOR THE LA SPINE INSTITUTE POSITION, please send all information to:

The Spine Institute PMR Fellowship
Timothy T. Davis, MD
1301 20th St Ste 400
Santa Monica CA 90404
Phone: (310) 828-7757

email all CV and personal statements to: [email protected]

 

[Finally M3]

Good lord.

Question for some of the attendings out here; are things (anesthesia v. PM&R, acred v. nonacred) this bad in private practice or is it just relegated to academia?

 

[drusso]

Good lord.

Question for some of the attendings out here; are things (anesthesia v. PM&R, acred v. nonacred) this bad in private practice or is it just relegated to academia?

The crux of the question is, "Who and what will set the standard of care for interventional pain medicine?"

The answer is far more complex than you might think...

 

[tchoupdoc]

Good lord.

Question for some of the attendings out here; are things (anesthesia v. PM&R, acred v. nonacred) this bad in private practice or is it just relegated to academia?

I am not fellowship trained. I am busier than I want to be, with three fluoro days a week, and offers for more. Why?

1) hospitals had fluoro suites underutilized. Hospitals like these procedures: cheap for them, and (hopefully) no inpatient stays.

2) I show up for clinic and procedures days on time, and see referalls quickly. This counts more than ANYTHING.

3) I refer out all RF, stim's, and cervicals. I work closely with 2 ACGME trained pain docs. We are not currently fighting over turf.

Academic vs private? I have a colleague, 20+ years general orthopedics and spine. No fellowship. His chairman asked how he would feel about a new, young fellowship trained spine surgeon moving into his clinic. His answer:

"This university will have one spine surgeon in this clinic. choose the one you feel most comfortable with."

Guess who was chosen?

 

[Disciple]

Well, the backlash from this fellowship turned out to be more political than i thought. I will step down from this fellowship director position for the NON-ACGME spine fellowship.

I will have to agree that the NON-ACGME spine program compromised my ACGME position at WLA VA/UCLA pain program.

The opportunity position will still be available, but will not be called UCLA at this time.

What a shame🙁

 

[Disciple]

The crux of the question is, "Who and what will set the standard of care for interventional pain medicine?"

The answer is far more complex than you might think...

We're all ears.

 

[drusso]

We're all ears.

Well, I was recently browsing through the American Pain Society's newsletter which details the new ACGME program training requirements. It's a good read:

http://www.ampainsoc.org/pub/bulletin/fall07/training.htm

Some interesting observations beginning with the very first sentence:

Until the advent of formal training programs in pain medicine 15 years ago, training in pain medicine was carried out through informal fellowships under the tutelage of self-trained experts, such as John J. Bonica, who developed the field (Rathmell & Brown, 2002).

Bonica developed the field? Single-handedly???

Bonica was indeed a major figure in pain medicine. But at the same time John Bonica was working, practicing, and laying the ground-work for multidisciplinary pain clinics across the country, a whole cadre of physiatrists were also at work diagnosing, treating, and rehabilitating people with persistent painful injuries. Many of the basic components of the multidisciplinary pain clinics and training model that Dr. Bonica espoused were straight out physiatric clinics that Dr. Bonica visited and was exposed to during his training in New York City and during his service in the US Army.

In fact, within medicine, the development of a multidisciplinary specialty centered on the diagnosis, treatment and rehabilitation of people with painful and disabling conditions predates Bonica by at least a couple of decades and begins with Howard Rusk, Frank Krusen, and Henry Betts. Now, this article is not meant to be a history lesson in pain medicine, but it seems to ignore some very important contributions by non-anesthesiologist pain practitioners toward developing the field of multidisciplinary pain medicine. Their story starts with Bonica. The problem is that these earlier practitioners did not think of themselves as "pain specialists." They took a broader view of what they did and were called physiatrists.

The article then moves to review the history of the development of the ACGME guidelines for subspecialty training in pain medicine. At the conclusion of this historical analysis, the authors frame the central question for training in this field, "the question to consider was, 'How could training pain medicine specialists be improved to eliminate the tremendous lack of consistency in what is offered from one pain subspecialty clinic to another?'"

Fundamentally, this is a question of standards.

The article then moves to recap some recent events within the last two to four years familiar to many posters on PainRounds. In fact, some of them were involved in the process. It would be interesting to hear from them, if, from their perspectives, the authors got the story right.

The new proposed standards that emerged are now currently the ones under which ACGME-accredited pain fellowship programs function:

Changes Established by 2007 ACGME Program Requirements for Fellowship Training in Pain Medicine (ACGME, 2007)

Only one ACGME accredited Pain Medicine fellowship program will be approved per institution.

The required didactic curriculum has been completely revised to incorporate the IASP Core Curriculum for Professional Education in Pain as the core of the curriculum.

All trainees will be required to gain verified exposure to all four parent specialties: anesthesiology, PM&R, neurology, and psychiatry, through defined clinical rotations with minimal documented clinical experience in each discipline.

While all programs will be required to expose trainees to the range of interventional pain modalities available for pain treatment, a subset of programs may offer expanded training in interventional pain medicine through an established "Advanced Interventional Track." Suggested features of this track include the following:

An expanded didactic curriculum on interventional pain medicine

Minimum suggested numbers of interventional procedures for each trainee

A requirement that program directors complete a final summary letter detailing

The specific interventions with which each trainee has demonstrated competence.

One of the most important changes is the development of the Advanced Interventional Track for selected pain fellowships. It seems to be that the purpose is to delineate between programs that offer EXPOSURE to various interventional pain treatments versus those that offer PROFICIENCY. I think it remains to be seen how this change will be implemented. It seems to suggest that some pain fellowships will have the track and others won't. For those that do, perhaps there will be 2 non-advanced slots and 1 advanced slot? Perhaps there will be some competition among fellows completing the standard 12 month fellowship for the additional 6-12 months of advanced interventional training? I don't know...

Still, according to the authors, the real benefit of this is for hospital credentialing, "This new requirement should serve as an invaluable aid to hospital credentialing committees as they grapple with credentialing new physicians (Lubenow & Rathmell, 2005)"

While this reform process has been nominally multidisciplinary, it has been largely *driven* by academic anesthiology-trained pain practitioners in tertiary care settings. This is laudable as I doubt that physiatry-trained pain practitioners would have had the clout to get around to the question of standards any time soon and carry the process foward on their own. It does, however, reveal a bias. How could it not?

At the very least, I think that bias could be summarized and restated as, "The standard for training in multidisciplinary pain medicine should be that the trainee trains in an academic anesthesiology department (in fact is preferably an anesthesiologist though mechanisms will allow for the consideration of others) in a tertiary-care medical center." It's not necessarily a bad bias, but certainly different from the direction in which many physiatric post-residency fellowship training opportunities have gone.

These opportunities have developed into "Interventional Spine" fellowships. These fellowships tend to be non-academic or private practice based, physiatric-based, and single-specialty and see an overlapping population of patients seen in traditional pain clinics. Setting aside the question of the merits of IS as a distinct sub-specialty compared to pain medicine, I wonder what will be the future of IS given the biases outlined above? Moreover, it seems to me that organized physiatry has almost completely surrendered its claim to the history of pain medicine and has chosen to invest in the interventional MSK/Spine training model almost exclusively. I think that ampaphb keeps track of the latest number of ACGME-accredited versus non-accredited PM&R fellowship numbers and can quote them off the top of his head!

Only time will tell if this gamble pays off for physiatry. But as defphiche, drrinnoo, lobelsteve and others can tell you, I think it has some pretty steep political costs associated with it.

 

[ampaphb]

Only one ACGME accredited Pain Medicine fellowship program will be approved per institution.

Could someone please define for me what constitutes an INSTITUTION? The plain language of the word would indicate that places like Harvard and UCLA would qualify as an institution, and thus only be able to maintain one fellowship, but in fact, both have more than that, and so clearly the word has a different meaning.

That being the case, I wonder why other "institutions" have not taken advantage of the same apparent loophole.

 

[drusso]

Could someone please define for me what constitutes an INSTITUTION? The plain language of the word would indicate that places like Harvard and UCLA would qualify as an institution, and thus only be able to maintain one fellowship, but in fact, both have more than that, and so clearly the word has a different meaning.

That being the case, I wonder why other "institutions" have not taken advantage of the same apparent loophole.

Spoken like a true lawyer...